Interprofessional Education — A Core Competency?

There is a thick stack of visiting nurse reports piled in a physician’s inbox. He skims through the officious, dense documents, vaguely recognizes most of the patients, and signs his name attesting to their veracity.

Later, a patient calls after hours. Apparently, there was a drug-drug interaction with her prescriptions that were faxed in earlier in the day. The pharmacist would not fill the prescriptions, and could the physician help?

Often I find myself thinking: Surely there must be a better way to practice medicine? A system that is less fractured, where patient care is collaborative, in real time. But what would this look like? And are we doing enough in medical education to foster such a vision of patient care?

The second item on this list, interdisciplinary teams, falls behind only patient-centered care. Why would the IOM highlight interdisciplinary teams as nearly the most important core competency? It recognizes the disjointed way we practice medicine. The authors write:

“There is generally a great lack of understanding among the professions for what each profession does, its level of training and education, and its existing or potential competencies….This situation is exacerbated by the fact that in the vast majority of educational settings, health professions are socialized in isolation, hierarchy is fostered, and individual responsibility and decision making are relied upon almost exclusively.” (p. 79)

At my medical school, the PA students had a test every Thursday. I would see them cramming in the library. We shared a few anatomy labs together. Later, on the wards, we would serve as clinical clerks – separately. Only as an attending, on the fly, did I learn about the PA’s scope of practice and collaborative care-giving. I never worked with a nurse practitioner. During residency, the pharmacist would call me only when I placed an order incorrectly.

Now, as a medical educator, I wonder if there is a better way.

What Would an Interdisciplinary Team Look Like?

The call from the IOM is to model these teams through interprofessional education. Only by training together, they reason, can a culture of communication, mutual respect, and shared values be fostered. We all practice in the same place. We all should learn in the same place.

There are only a few examples in medical education literature that describe successful interprofessional training experiences. One study created student teams in medicine, nursing, physical therapy, and occupational therapy. The purpose of the project was for the teams to provide interprofessional care plans for orthopedic and rheumatology patients, including interprofessional hand-offs. How did it go? Using qualitative analysis, the students were generally positive. One medical student responded, “You need to adapt to understand that training ward is about holistic patient care… so you need to be a team player.”

The gist of these studies is that the learners grow to appreciate each other’s perspective, recognize the unique role each discipline can offer, and work collaboratively for the best outcome of the patient.

Is Interprofessional Education the Way to Go?

Although this research is promising, I am not aware of any findings that conclusively demonstrate improved patient outcomes resulting from interprofessional education. A Cochrane Review of 15 studies was inconclusive about the superiority of interprofessional education on health care outcomes and professional practice.

There are also some philosophical issues at play here. On the one hand, there may be some economies of scale: if APRN students, PA students, and medical students all need to learn anatomy or physiology, then perhaps all could attend the same lectures. History taking, the physical exam, and professionalism — so much could be taught to all disciplines simultaneously.

On the other hand, the professions are different and perhaps blurring the roles of each is not in each one’s best interest. When I asked the opinion of a colleague at another medical school — one that has rolled out a comprehensive interprofessional curriculum where medical, nursing, and PA students interact early on in their training — she remarked, “The medical students are training to be doctors. The nursing students are training to be nurses. The PA students are training to be PAs. But in this curriculum, it looks like everyone is being trained the same. How are they different?” A fair question indeed.

In the past, the health professions may have been “socialized in isolation” as the IOM says. And yet, is it possible for too much collaboration and not enough identity formation?

At this point, the Med Ed community are still trying to figure it out. Pharmacists are showing up on morning rounds more. Social workers, medical home nurses, and physicians “huddle” before the morning clinic session. We look each other in the eye. We ask clarifying questions of one another in real time to smooth over bumps in patient care. To me, this feels right and makes sense – certainly more sense than blindly signing those “in basket” VNA orders.

Benjamin R. Doolittle, MD, is an expert in burnout and wellness in residents and physicians. He is an associate professor and program director of internal medicine and pediatrics at the Yale University School of Medicine and the medical director of the Yale Medicine-Pediatrics Practice.

2 Comments

Your story seems have critical problems to begin with. First, why a huge stack of VNA orders? This could mean too many patients for this one Dr or piling up of old olders which accumulated. Why? Second, when the original medication orders were written, any interaction should have been identified. Why did that not happen? third, if the pharmacist picked up an interaction, why did he/she not call the signing Dr at that time to verify?

I would argue that these situations have nothing to do with “education” per se, but rather with common sense, which truly cannot be taught, but has to be self-learned.

Being an expert in burnout and wellness, you should be aware that common sense is not utilized in practice because our brains are cluttered with useless items, like checking MU boxes or documenting mundane items to code correctly. All this leads to mind fatigue and loss of common sense. How do you plan to change this, Dr. Doolittle?

Dear Dr. Cavale, Many thanks for your comments. I am glad that someone cares enough to write a response! My illustrations were extreme to highlight a point. Primary care physicians often cite the challenges of paperwork and phone calls as detracting from their interaction with patients. Maybe better integration with interprofessional teams can help with this? I believe also that figuring out how interprofessional teams best work together needs to happen during training – and not afterwards when there is a stack of VNA orders. I share with you the challenge of checking MU boxes and correct coding. Indeed, I wish “common sense” were more “common.” We are all in this together and I wish you the best. ~ With warm regards, Ben

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